Oral Health: Nursing Assessment and Interventions - Nursing Best Practice Guideline - Registered Nurses' Association of ...

 
Oral Health: Nursing Assessment and Interventions - Nursing Best Practice Guideline - Registered Nurses' Association of ...
December 2008

             Nursing Best Practice Guideline
                           Shaping the Future of Nursing

Oral Health:
Nursing Assessment and Interventions
Oral Health: Nursing Assessment and Interventions - Nursing Best Practice Guideline - Registered Nurses' Association of ...
Greetings from Doris Grinspun
                  Executive Director
                  Registered Nurses’ Association of Ontario

                  It is with great excitement that the Registered Nurses’ Association of Ontario (RNAO)
                  presents this guideline, Oral Health: Nursing Assessment and Interventions to the health
                  care community. Evidence-based practice supports the excellence in service that nurses
                  are committed to delivering in our day-to-day practice. RNAO is delighted to provide this
                  key resource to you.

RNAO offers its heartfelt thanks to the many individuals and institutions that are making our vision for
Nursing Best Practice Guidelines (BPGs) a reality: the Government of Ontario for recognizing our ability to
lead the program and providing multi-year funding: Irmajean Bajnok, Director, RNAO International Affairs
and Best Practice Guidelines (IABPG) Programs, for her expertise and leadership in advancing the
production of the BPGs; each and every Team Leader involved, and for this BPG in particular – Toba Miller
– for her superb stewardship, commitment and, above all, exquisite expertise. Also thanks to Heather
McConnell, Associate Director, IABPG Program, who provided the coordination and worked intensely to see
this BPG move from concept to reality. A special thanks to the BPG Panel – we respect and value your
expertise and volunteer work. To all, we could not have done this without you!

The nursing community, with its commitment and passion for excellence in nursing care, is providing the
knowledge and countless hours essential to the development, implementation, evaluation and revision of
each guideline. Employers have responded enthusiastically by nominating best practice champions,
implementating and evaluating the guidelines and working towards a culture of evidence-based practice.

Successful uptake of these guidelines requires a concerted effort from nurse clinicians and their health care
colleagues from other disciplines, from nurse educators in academic and practice settings and from
employers. After lodging these guidelines into their minds and hearts, knowledgeable and skillful nurses
and nursing students need healthy and supportive work environments to help bring these guidelines to
practice actions.

We ask that you share this guideline with members of the interdisciplinary team as there is much to learn
from one another. Together, we can ensure that the public receives the best possible care every time they
come in contact with us. Let’s make them the real winners in this important effort!

Doris Grinspun, RN, MScN, PhD(c), O. ONT.
Executive Director
Registered Nurses’ Association of Ontario
Oral Health: Nursing Assessment and Interventions - Nursing Best Practice Guideline - Registered Nurses' Association of ...
Nursing Best Practice Guideline

Oral Health: Nursing Assessment
and Interventions
Disclaimer
These guidelines are not binding on nurses or the organizations that
employ them. The use of these guidelines should be flexible based on
individual needs and local circumstances. They neither constitute a
liability nor discharge from liability. While every effort has been made to
ensure the accuracy of the contents at the time of publication, neither the
authors nor the Registered Nurses’ Association of Ontario (RNAO) give
any guarantee as to the accuracy of the information contained in them
nor accept any liability, with respect to loss, damage, injury or expense
arising from any such errors or omission in the contents of this work.

Copyright
With the exception of those portions of this document for which a specific
prohibition or limitation against copying appears, the balance of this
document may be produced, reproduced and published in its entirety,
without modification, in any form, including in electronic form, for
educational or non-commercial purposes. Should any adaptation of the
material be required for any reason, RNAO written permission must be
obtained. Appropriate credit or citation must appear on all copied
materials as follows:

Registered Nurses’ Association of Ontario. (2008) Oral Health: Nursing
Assessment and Interventions. Toronto, Canada. Registered Nurses’
Association of Ontario.

                                Registered Nurses’ Association of Ontario
                International Affairs and Best Practice Guideline Program
                                                           158 Pearl Street
                                                Toronto, Ontario M5H 1L3
                                     Website: www.rnao.org/bestpractices

                                   1
Oral Health: Nursing Assessment and Interventions - Nursing Best Practice Guideline - Registered Nurses' Association of ...
Oral Health: Nursing Assessment and Interventions

Development Panel Members

Toba Miller RN, MScN, MHA, GNC(C)              Lisebeth Gatkowski, RN, BScN, CPMHN(C)
Team Leader                                    Community Nurse
Advanced Practice Nurse – Rehabilitation       Specialized Assessment & Treatment and
The Ottawa Hospital                            Acute Mental Health Services
Ottawa, Ontario                                St. Joseph’s Healthcare: Centre for
                                               Mountain Health Services
Tabatha Bowers, RN, BScN, MN, GNC(C)           Hamilton, Ontario
Clincial Nurse Specialist – Geriatrics
The Scarborough Hospital                       Marina Kaufman, RN, BScN
Scarborough, Ontario                           Nurse Manager
                                               ENT, Plastic Surgery
Donna Bowes, RDH-Dip. DH,                      Head and Neck Oncology
Dip. Gerontology, BHA                          University Health Network –
Dental Coordinator                             Toronto General Hospital
Halton Region Health Department                Toronto, Ontario
Oakville, Ontario
                                               Suzanne McGettigan, RN, MSN, CRNP,
Dr. Jane Chalmers, BDSc, MS, PhD, DABSCD       ANP-BC, AOCN
Associate Professor                            Nurse Practitioner
Geriatric and Special Needs Program            Department of Medicine,
Preventive and Community Dentistry             Hematology-Oncology Division
College of Dentistry, University of Iowa       University of Pennsylvania Health System
Iowa City, Iowa                                Philadelphia, Pennsylvania

Cheryl Duffy, RN, RDH                          Linda Nusdorfer, RN, BScN, MN, CNCC(C)
Director of Educational Services               Clinical Nurse Specialist – Critical Care
Hygiene Mentor prn                             University Health Network –
Penetanguishene, Ontario                       Toronto General Hospital
                                               Toronto, Ontario
Una Ferguson, RN, GNC(C), CPMHN(C)
Staff Nurse                                    Salma Syed, MHSc, SLP, Reg CASLPO
Royal Ottawa Health Care Group                 Speech-Language Pathologist
Ottawa, Ontario                                The Scarborough Hospital
                                               Scarborough, Ontario

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Oral Health: Nursing Assessment and Interventions - Nursing Best Practice Guideline - Registered Nurses' Association of ...
Nursing Best Practice Guideline

Mary-Lou van der Horst, RN, BScN, MScN, MBA                           Heather McConnell, RN, BScN, MA(Ed)
Regional Best Practice Coordinator                                    Associate Director
Long-Term Care                                                        International Affairs and Best Practice
Central South Region                                                  Guidelines Program
The Village of Wentworth Heights LTC Home                             Registered Nurses’ Association of Ontario
Ministry of Health and Long-Term Care                                 Toronto, Ontario
Hamilton, Ontario
                                                                      Meagan Cleary, BA
Minn Yoon, BSc, PhD(C)                                                Project Coordinator
Doctoral Student                                                      International Affairs and Best Practice
University of Toronto                                                 Guidelines Program
Toronto, Ontario                                                      Registered Nurses’ Association of Ontario
                                                                      Toronto, Ontario

Declarations of interest and confidentiality were made by all members of the guideline development panel.
Further details are available from the Registered Nurses’ Association of Ontario.

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Oral Health: Nursing Assessment and Interventions - Nursing Best Practice Guideline - Registered Nurses' Association of ...
Oral Health: Nursing Assessment and Interventions

Stakeholder Acknowledgement

Stakeholders representing diverse perspectives, both nationally and internationally, were solicited for their
feedback. The Registered Nurses’ Association of Ontario wish to acknowledge the following individuals/groups
for providing feedback and their contribution to the development of this nursing best practice guideline:

Marianne Beckstead, RN, MN, CDE                 Clinical Nurse Specialist, University Health Network, Toronto, Ontario

Dr. Annie Bolland, BSc, DDS                     Dentist, Bayfield Dental, Barrie, Ontario

Maxine Borowko, RDH, Dip. Dental Therapy,       Dental Hygienist, Fraser Health Authority, Maple Ridge, British Columbia
Cert. Voc/Tec ED, BGS

Jennifer Brown, RN                              River Glen Haven Nursing Home, Sutton, Ontario

Debbie Burke, RN, CON(C), CHPCN(C)              Clinical Education Leader, Chatham Kent Health Alliance, Chatham, Ontario

Kathy Cohen, RD, RDH                            Clinical Dietitian, University Health Network, Toronto Western Hospital,
                                                Toronto, Ontario

Marliane Cole, RN, BScN, CNCC

Pamela Cybulski, BA (Health Studies), CNCC(c)   Critical Care Educator, William Osler Health Centre, Brampton, Ontario

Francine De Marchi, RDH, BA                     Dental Hygienist, Niagara College, Welland, Ontario

Denise Dodman, RN, BScN, GNC(C)                 Advanced Practice Leader, Chatham-Kent Health Alliance, Chatham, Ontario

Leeann Donnelly, RDH, Dip DH, BDSc,             Distance Education Instructor, University of British Columbia, Vancouver, BC
MSc, PhD (student)

Dr Heather F. Frenkel, BDS, PhD                 Special Care Dentist, SW Region Dental Postgraduate Department, Bristol
                                                Dental Hospital, Bristol, United Kingdom

Anne Fu, BScN, MA(Ed), CNCC(C)                  Educator, Critical Care and Telemetry,York Central Hospital,
                                                Richmond Hill, Ontario

Ruby Funnell, RN                                Staff Nurse, The Brant Centre, Burlington, Ontario

Julie Gregg, RN, BScN, MAdEd                    Coordinator, Member Relations and Development, College of Registered
                                                Nurses of Nova Scotia, Halifax, Nova Scotia

Mary Griffiths, RN, BScN, CPRP, NCTAS           Staff Nurse, St. Joseph’s Healthcare, Hamilton, Ontario
Robert Hawkins, BSc, DDS, DDPH                  Dental Consultant, Halton Region Health Department, Oakville, Ontario

Carolyn Hendry, RN, BScN                        Staff Nurse, Leisureworld Caregiving Centre, North Bay, Ontario

Julie Kaine, RN                                 Staff Nurse, St. Joseph's Health Centre, Guelph, Ontario

Linda Jamieson, RDH, BA, MHS                    Coordinator, Dental Programs, Georgian College, Orillia, Ontario

Joy Kellen, RN, BN, MSc                         Policy Coordinator, Saskatchewan Registered Nurses Association, Regina,
                                                Saskatchewan

Marie Lochhead, RDH, MSc                        Dental Hygienist, Drs. Gravitis and Mader, St. Catharines, Ontario

Laurie Magill, RDH, Associate                   Professor, Confederation College, Thunder Bay, Ontario
of Science Degree in Dental Hygiene

Dana Martin, RN, BScN                           FNIH, Health Canada, Gane Yohs Health Centre, Six Nations
                                                of the Grand River, Ontario

Rosemary Martino, MA, SLP(C), MSc, PhD          Professor, University of Toronto, Toronto, Ontario

Max Massad Jr., RDH, BSc                        Professor, St. Clair College, Windsor, Ontario

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Nursing Best Practice Guideline

Faye Matthews, MLT, CIC                         Halton Healthcare Services, Oakville, Ontario

Kerry McCall-Johnston, RN, BScN                 Clinical Practice Manager, Niagara Municipal Homes, Region of Niagara,
                                                Thorold, Ontario

Lynda McKeown, RDH, HBA, MA                     Researcher/Clinical Director, Breath Odour Clinic, Thunder Bay, Ontario

Janet McNabb, RN                                Staff Nurse, Algonquin Nursing Home, Mattawa, Ontario

Louise Moran, DRC, RN, LNC, BAAJ                Director of Resident Care, Cheltenham Long-Term Care, Toronto, Ontario

Laura Myers, RDH, DipDH, BA                     Director of Education, Canadian Dental Hygienists Association, Ottawa, Ontario

Jim Natis, BA, BSW, MSW                         Social Worker, University Health Network, Toronto General Hospital Division,
                                                Toronto, Ontario

Donna Pickles, RN, DDC                          Staff Nurse, Clarion Nursing Home, Stoney Creek, Ontario
Barb Pond, RN, Certification In Infection Control Staff Nurse, Norfolk General Hospital, Simcoe, Ontario

Ingrid Popaleni, RN                             Case Manager, Community Care Access Centre of Halton, Burlington, Ontario

Gillian Revie, RN, BScN, BA, CNCC(C)            Nurse Educator ICU, CCU, Credit Valley Hospital, Mississauga, Ontario

Fran Richardson, RDH, BScD, MEd                 Registrar, College of Dental Hygienists of Ontario, Toronto, Ontario

Krista Robinson-Holt, RN, BScN, MN              Director of Health Planning and Research, Ontario Long Term Care Association,
                                                Markham, Ontario

Ellen B.Ross, CPDA – Dip. Gerontology           Dental Health Promoter, Region of Halton Health Department, Oakville, Ontario

Lynette Royeppen, RN                            Staff Nurse, Mount Nemo Christian Nursing Home, Burlington, Ontario

Susan L. Rudin, RDH, BSc, MSPH                  Coordinator of Hygiene Clinic, George Brown College, Toronto, Ontario

Anne-Marie Rumble, RN                           Meadow Park (Chatham) Inc.– LTC Facility, Chatham, Ontario

Deborah Schott, RN, BScN (student)              Clinical Educator, Medical Program, Royal Victoria Hospital, Barrie, Ontario

Ferne Schwartzentruber, RN                      Staff Nurse, Caressant Care Nursing Home, Woodstock, Ontario

Joyce See, MScN                                 Director, Halton Region Health Department, Oakville, Ontario

John Shaw                                       General Manager, maxill inc., St. Thomas, Ontario

Carol Skanes, RN, MN                            Staff Nurse, University Health Network, Toronto, Ontario

Maggie Smith, MA, SLP, Reg CASLPO               Speech-Language Pathologist, Hamilton Health Sciences, Hamilton, Ontario

Catriona M. Steele, PhD, S-LP(C),               Research Scientist and Corporate Practice Leader for Speech-Language
CCC-SLP, Reg. CASLPO                            Pathology and Audiology, Toronto Rehabilitation Institute, Toronto, Ontario

Tracey Tait, RN, BA Gerontology                 Staff Nurse, Millennium Trail Manor, ConMed Healthcare Group,
                                                Niagara Falls, Ontario

Lisa Valentine, RN, BScN, MN                    Clinical Nurse Specialist/Case Manager, Sunnybrook Health Sciences Centre –
                                                Regional Stroke Strategy, North and East GTA, Toronto, Ontario

Lisa Vaughan, RN, BScN                          Director of Nursing, Grandview Lodge, Dunnville, Ontario

Janice Verheul, RN                              Staff Nurse, Alexander Place LTC, Waterdown, Ontario

Inger Wårdh, DDS, PhD                           Professor, Karolinska Institute, Huddinge, Sweden

Daphne Walker, BA, CBT Dip.                     Niagara Health System, Welland, Ontario

Kelley R. Wilson, RDH                           Dental Hygienist, Whitby Mental Health Centre, Whitby, Ontario

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Oral Health: Nursing Assessment and Interventions

Joyce A. Wimmer, RDH                          Bridgepoint Health, Toronto, Ontario

Nancy Young, RN, BSCN, MSCN, CTRC             Clinical Specialist, Hamilton Health Sciences, Hamilton, Ontario

Baiba Zarins, RN, BScN, MHS                   Project Manager, Best Practice Guidelines, University Health Network,
                                              Toronto, Ontario

In order to ensure that there were a range of opportunities to gather the perspectives of the client,
family and caregiver in relation to oral health, several focus groups were held in various sites in Ontario.
The RNAO would like to acknowledge those that participated and provided their feedback.

a) Focus Group – Long-term care

Ruth Auber, RN, DipHE (nursing)               The Village of Erin Meadow, Mississauga, Ontario

Noëlla Black, RPN                             The Village of Taunton Mills, Whitby, Ontario

Anna Crocco, RN                               The Village of Tansley Woods, Burlington, Ontario

Lorraine Denman, Consumer Representative      President, Resident’s Council, St. Joseph’s Villa, Dundas, Ontario

Maria Dibiase, RN, BA, BScN                   The Village of Wentworth Heights, Hamilton, Ontario

Anita Forester, RN                            The Village of Riverside Glen, Guelph, Ontario

Jacqueline Gosse, RN                          The Village of Riverside Glen, Guelph, Ontario

Frederika Grunthal, Consumer Representative   Member, Resident’s Council, St. Joseph’s Villa, Dundas, Ontario

Jela Jakouljevic, RN                          The Village of Humber Heights, Etobicoke, Ontario

Tamara Johnson, Unit Manager                  St. Joseph’s Villa, Dundas, Ontario
Health & Wellness

Cristina Locatelli, RN                        The Village of Taunton Mills, Whitby, Ontario

Mary Marcella, RN                             The Village of Wentworth Heights, Hamilton, Ontario

Jennifer Martino, RPN                         The Village of Humber Heights, Etobicoke, Ontario

Wendy Miller, RN                              The Village of Winston Park, Kitchener, Ontario

Pat Morris, RPN                               The Village of Erin Meadows, Mississauga, Ontario
Jennifer Meagan Newbury, RN                   The Village of Tansley Woods. Burlington, Ontario
Edwena Nolan, RN, BN                          The Village of Sandalwood Park, Brampton, Ontario

Sylvia Pippard, Consumer Representative       Member, Resident’s Council, St. Joseph’s Villa, Dundas, Ontario

Chris-Anne Preston, RN                        The Village of Winston Park, Kitchener, Ontario

Linda Quest, RDH                              St. Joseph’s Villa, Dundas, Ontario

Dale Shantz, RN                               Oakwood Retirement Communities, Kitchener, Ontario

Pamela Wiebe, RPN                             The Village of Tansley Woods, Burlington, Ontario

Beth Woodworth, Unit Manager                  St. Joseph’s Villa, Dundas, Ontario

b) Focus Group – Mental Health
                                              Inspiration Place, Hamilton, Ontario

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Nursing Best Practice Guideline

How to Use This Document
This nursing best practice guideline                 is a comprehensive document providing resources
necessary for the support of evidence-based nursing practice. The document should be reviewed and then
applied to both specific needs of the organization or practice setting/environment, and to meet the needs
and wishes of the client. This guideline should not be applied in a “cookbook” fashion, but used as a tool to
assist in decision-making for individualized client care, and in ensuring that appropriate structures and
supports are in place to provide the best possible care.

Nurses, other health care professionals and administrators who are leading and facilitating practice changes
will find this document valuable for the development of policies, procedures, protocols, educational
programs, assessment and documentation tools. It is recommended that this guideline be used as a resource
tool. Nurses providing direct client care will benefit from reviewing the recommendations, the evidence in
support of the recommendations, and the process that was used to develop the guidelines.

It is highly recommended that practice settings/environments adapt these guidelines in formats that
would be user-friendly for daily use. This guideline has some suggested formats for such local adaptation
and tailoring.

Organizations wishing to use the guideline may decide to do so in a number of ways:
■ Assess current nursing and health care practices using the recommendations in the guideline.
■ Identify recommendations that will address identified needs or gaps in services.

■ Systematically develop a plan to implement the recommendations using associated tools

  and resources.

The Registered Nurses’ Association of Ontario (RNAO) is interested in hearing how you have implemented
this guideline. Please contact us to share your story. Implementation resources will be made available
through the RNAO website to assist individuals and organizations to implement best practice guidelines.

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Oral Health: Nursing Assessment and Interventions

Table of Contents
Summary of Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Interpretation of Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Responsibility for Guideline Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Purpose and Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Development Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Definition of Terms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Background Context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Practice Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Education Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Organization and Policy Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Research Gaps and Future Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Evaluation and Monitoring of Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Implementation Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Process for Review and Update of Guideline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

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Nursing Best Practice Guideline

Appendix A – Search Strategy for Existing Evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Appendix B – Glossary of Clinical Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Appendix C – Algorithm Guide to Oral Health Assessment and Interventions . . . . . . . . . . . . . . . . . . . . . . . 65
Appendix D – Oral Hygiene History – Sample Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
Appendix E – Oral Health Assessment Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Appendix F – Sample Care Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Appendix G – Brief Reference – Oral Hygiene Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Appendix H – Medications That May Impact on Oral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Appendix I – Denture Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Appendix J – Tooth Brushing Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Appendix K – Approches to Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Appendix L – Website Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Appendix M – Sample Financial Assistance Programs and Other Resources for Dental Treatment . . . . . 85
Appendix N – Description of Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

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Oral Health: Nursing Assessment and Interventions

Summary of Recommendations
   RECOMMENDATION                                                                                     *LEVEL OF EVIDENCE

  Practice Recommendations
  1.   Nurses should be aware of their personal oral hygiene beliefs and practices, as these may influence          III
       the care they provide to their clients.

  2.   As part of their client admission assessment, nurses obtain an oral health history that includes             IV
       oral hygiene beliefs, practices and current state of oral health.

  3.   Nurses use a standardized, valid and reliable oral assessment tool to perform their initial and              III
       ongoing oral assessment.

  4.   Oral health status information is regularly reviewed with all members of the health care team to             IV
       monitor client progress and facilitate the development of an individualized plan of care.

  5.   Nurses provide, supervise, remind or cue oral care for clients at least twice daily, on a routine basis.     IV
       This includes clients who:
       ■ have diminished health status;
       ■ have a decreased level of consciousness; and
       ■ who have teeth (dentate) or do not have teeth (edentate).

  6.   Nurses provide or supervise the provision of oral care for clients at risk for aspiration.                   III

  7.   Nurses provide ongoing education to the client and/or family members regarding oral care.                    III

  8.   Nurses are knowledgeable of oral hygiene products and their applications as they pertain to their            IV
       specific client populations.

  9.   Nurses are aware of treatments and medications that impact on the oral health of clients.                    IV

  10. Nurses use appropriate techniques when providing oral care to clients.                                        IV

  11. Nurses advocate for referral for those clients who require consultation with an oral health                   IV
      professional (e.g. dental hygienist, denturist, dentist).

  12. Nurses ensure that all oral health-related history, assessment and care be documented.                        IV

  Educational Recommendations
  13. Nurses require appropriate oral health knowledge and skills acquired through entry-level                      IV
      nursing education programs, workplace orientation programs and ongoing professional
      development opportunities.

  14. Nurses who provide oral hygiene care to their clients, either directly or indirectly, must participate        IV
      in, and complete, appropriate oral hygiene education and training.

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Nursing Best Practice Guideline

    RECOMMENDATION                                                                                    *LEVEL OF EVIDENCE

    Organization and Policy Recommendations
    15. Health care organizations develop oral health care policies and programs that recognize the components       IV
        of oral health assessment, oral hygiene care and treatment are integral to quality client care.

    16. Health care organizations develop partnerships and increase capacity among providers to deliver              IV
        collaborative practice models that improve the oral health care they provide to their clients.

    17. Health care organizations implement continuing education opportunities for nurses and support                IV
        them to complete oral hygiene education and training that is applicable to their health care setting.

    18. Health care organizations develop oral hygiene care standards that are based on the best available           III
        evidence and ensure they are implemented and monitored as part of the organization’s
        commitment to providing quality oral health care and services.

    19. Organizations should encourage and offer support, including time and resources, for nurses                   IV
        to participate in oral hygiene research to assist in better understanding the issues related to oral
        hygiene care provision in various health care settings.

    20. Oral hygiene care is monitored and evaluated as part of the organization’s quality management                IV
        program, utilizing a variety of quantitative and qualitative approaches.

    21. Organizations develop a plan for implementation of best practice guideline recommendations                   IV
        that include:
        ■ An assessment of organizational readiness and barriers/facilitators.
        ■ Involvement of all members (whether in a direct or indirect supportive function)
           who will contribute to the implementation process.
        ■ Ongoing opportunities for discussion and education to reinforce the importance of best practices.
        ■ Dedication of a qualified individual to provide the support needed for the education
           and implementation process.
        ■ Ongoing opportunities for discussion and education to reinforce the importance of best practices.
        ■ Opportunities for reflection on personal and organizational experience in implementing guidelines.
        ■ Strategies for sustainability.

* Please refer to page 12 for details regarding the interpretation of evidence.

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Oral Health: Nursing Assessment and Interventions

Interpretation of Evidence
Level of Evidence

  Ia Evidence obtained from meta-analysis of randomized controlled trials.

  Ib Evidence obtained from at least one randomized controlled trial.

  IIa Evidence obtained from at least one well-designed controlled study without randomization.

  IIb Evidence obtained from at least one other type of well-designed quasi-experimental study,
      without randomization.

  III Evidence obtained from well-designed non-experimental descriptive studies, such as
      comparative studies, correlation studies and case studies.

  IV Evidence obtained from expert committee reports or opinions and/or clinical experiences
      of respected authorities.

Responsibility for Guideline Development
The Registered Nurses’ Association of Ontario (RNAO), with funding from the Government
of Ontario, has embarked on a multi-year project of nursing best practice guideline development, pilot
implementation, evaluation, dissemination and support of uptake. One of the areas of emphasis is on
nursing interventions related to oral health assessment and management in those populations with special
needs. This guideline was developed by a panel of nurses and other health professionals convened by the
RNAO, conducting its work independent of any bias or influence from the Ontario Government.

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Nursing Best Practice Guideline

Purpose and Scope
Best practice guidelines are systematically developed statements to assist practitioners’ and clients’
decisions about appropriate health care (Field & Lohr, 1990). This best practice guideline aims to assist nurses
working in diverse practice settings provide evidence-based oral health care to adults with special needs.
Within the scope of this guideline, those with special needs may include older adults, those who are
medically compromised, intellectually challenged, physically challenged, and/or have severe and persistent
mental illness. Many may be frail or dependent upon caregivers to help with their activities of daily living.
These adults may live in the community or may be in institutions. It should be noted that children have
special assessment needs related to developmental stages that are beyond the scope of this guideline.

The guideline will focus on specific vulnerable populations over the age of 18 years (those who need
assistance to meet their oral hygiene needs) and will address:
■ assessment of oral health (incorporating screening);

■ assessment of current oral hygiene practices; and

■ interventions (incorporating care plan development).

The goal of this document is to provide nurses with recommendations, based on the best available
evidence, to support the provision of oral hygiene care to adults with special needs.

The clinical questions to be addressed by the guideline include:
■ What are the risk factors associated with poor oral hygiene?

■ What are the current attitudes and beliefs of nurses providing oral hygiene care?

■ What are the optimal oral hygiene interventions for oral health in vulnerable populations?

This guideline contains recommendations for Registered Nurses (RNs) and Registered Practical Nurses
(RPNs) on best nursing practices in the area of vulnerable adults requiring assistance with their oral hygiene
care. It is intended for nurses who are not necessarily experts in this area of practice who work in a variety
of practice settings across the continuum of care. It is acknowledged that the individual competencies of
nurses varies between nurses and across categories of nursing professionals, and are based on knowledge,
skills, attitudes, critical analysis and decision-making that are enhanced over time by experience and
education. It is expected that individual nurses will perform only those aspects of oral hygiene interventions
for which they have received appropriate education and experience, and that they will seek appropriate
consultation in instances where the client’s care needs surpass their ability to act independently.

It is acknowledged that effective health care depends on a coordinated interdisciplinary approach
incorporating ongoing communication between health professionals and clients /families.

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Oral Health: Nursing Assessment and Interventions

Development Process
In July of 2006, a panel of nurses, oral health professionals (including registered dental hygienists and
a dentist) and speech-language pathologists with expertise in the management of oral hygiene care from a
range of practice settings was convened under the auspices of the RNAO. The panel discussed the purpose
of their work, and came to consensus on the scope of the best practice guideline. Subsequently, a search of
the literature for clinical practice guidelines, systematic reviews, relevant research studies and other types
of evidence was conducted. See Appendix A for details of the search strategy and outcomes.

Several international guidelines have reviewed the evidence related to oral hygiene, and it was determined
that a critical appraisal of these existing guidelines would serve to inform the development of this
guideline. A total of three clinical practice guidelines on the topic of oral hygiene were identified that met
the following initial inclusion criteria:
■ published in English;

■ developed in 2002 or later;

■ strictly on the topic of oral hygiene;

■ evidence-based; and

■ the guideline is available and accessible for retrieval.

Members of the development panel critically appraised these three guidelines using the Appraisal of
Guidelines for Research and Evaluation Instrument (AGREE Collaboration, 2001). As all met the requirements of
the AGREE review, a decision was made to work with all three of these guidelines to inform the guideline
development process. These were:

  ■   Research Dissemination Core (2002). Oral hygiene care for functionally dependent and cognitively
      impaired older adults. Iowa City (IA): University of Iowa Gerontological Nursing Interventions
      Research Center.

  ■   Rubenstein, E.B., Peterson, D.E., Schubert, M., Keefe, D., McGuire, D., Epstein, J., Elting, L.S.,
      Fox, P.C., Cooksley, C. & Sonis, S.T. (2004). Clinical practice guidelines for the prevention and
      treatment of cancer therapy-induced oral and gastrointestinal mucositis. Cancer Journal,
      100(S9), pg. 2026-2046.

  ■   Singapore Ministry of Health (2004). Nursing Management of Oral Hygiene. Singapore: Singapore
      Ministry of Health.

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Nursing Best Practice Guideline

The panel members divided into subgroups to undergo specific activities using the short-listed guidelines,
evidence summaries, studies and other literature for the purpose of drafting recommendations for
nursing assessment and interventions. This process resulted in the development of practice, education,
and organization and policy recommendations. The panel members as a whole reviewed the first draft
of recommendations, discussed gaps, reviewed the evidence and came to consensus on a final set of
recommendations.

A draft was submitted to a set of external stakeholders for review and feedback; an acknowledgement of
these reviewers is provided at the front of this document. Stakeholders represented various health care
professional groups, clients and families, as well as professional associations. External stakeholders were
provided with specific questions for comment, and the opportunity to give overall feedback and general
impressions. In addition, client and family focus groups in long-term care and mental health were
conducted to gather feedback and input to inform the guideline development process.

The feedback from stakeholders was compiled and reviewed by the development panel; discussion and
consensus resulted in revisions to the draft document prior to publication. An acknowledgement of the
focus group members and stakeholder reviewers is provided at the front of this document.

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Oral Health: Nursing Assessment and Interventions

Definition of Terms
  Client: A client is a person with whom the nurse is engaged in a therapeutic relationship. In most
  circumstances, the client is an individual but may also include family members and/or substitute
  decision-makers (College of Nurses of Ontario, 2005).

  Clinical Practice Guidelines or Best Practice Guidelines: Systematically developed
  statements to assist practitioner and client decisions about appropriate health care for specific
  clinical (practice) circumstances (Field & Lohr, 1990).

  Consensus: A process for making policy decisions, not a scientific method for creating new
  knowledge. Consensus development makes the best use of available information, be that scientific
  data or the collective wisdom of the participants (Black et al., 1999).

  Education Recommendations: Statements of educational requirements and educational
  approaches/strategies for the introduction, implementation and sustainability of the best practice
  guideline.

  Oral Health: The optimal state of the mouth and normal functioning of the oral cavity without
  evidence of disease.

  Oral Hygiene: Oral hygiene is the practice of keeping the mouth clean and healthy by brushing
  and flossing to prevent tooth decay and gum disease.

  Organization and Policy Recommendations:                     Statements of conditions required for a
  practice setting that enables the successful implementation of the best practice guideline. The
  conditions for success are largely the responsibility of the organization, although they may have
  implications for policy at a broader government or societal level.

  Practice Recommendations:               Statements of best practice directed at the practice of health
  care professionals that are ideally evidence-based.

  Randomized Controlled Trials: Clinical trials that involve at least one test treatment and one
  control treatment, concurrent enrollment and follow-up of the test- and control-treated groups, and
  in which the treatments to be administered are selected by a random process.

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  Stakeholder:       An individual, group or organization with a vested interest in the decisions and
  actions of organizations who may attempt to influence decisions and actions (Baker et al., 1999).
  Stakeholders include all individuals or groups who will be directly or indirectly affected by the change
  or solution to the problem.

  Systematic Review: An application of a rigorous scientific approach to the preparation of a
  review article (National Health and Medical Research Centre, 1998). Systematic reviews establish where the
  effects of health care are consistent and research results can be applied across populations, settings
  and differences in treatment (e.g. dose), and where effects may vary significantly. The use of explicit,
  systematic methods in reviews limits bias (systematic errors) and reduces chance effects, thus
  providing more reliable results upon which to draw conclusions and make decisions (Alderson, Green &
  Higgins, 2004).

Background Context
Significance of Oral Hygiene on Health
It is an expectation by both clients and families that when entering a health care provider’s office, hospital,
long-term facility or receiving care within the home, that the individual’s health care needs will be met;
however, there is evidence that oral health care is not addressed to the same level as other care needs
(Frenkel, Harvey & Needs, 2002).

Research has consistently indicated that oral health has a significant impact on quality of life (Almomani,
Brown & Williams, 2006; Chalmers, Carter & Spencer, 2002; Petersen, Bourgeois, Ogawa, Estupinan-Day & Ndiaye, 2005;
Sheiham, 2005; Watt, 2005). Good oral health enables individuals to communicate effectively, to eat and enjoy
a variety of foods (Watt, 2005). Additionally, poor oral health affects the ability to sleep well, especially in the
presence of pain, and impacts on a person’s perception of self – both their self-esteem and self-confidence.
Petersen of the World Health Organization, (2005), states “oral diseases such as dental caries, periodontal
disease, tooth loss, oral mucosal lesions and oropharyngeal cancers human immunodeficiency
virus/acquired immunodeficiency syndrome (HIV/AIDS) – related oral disease and orodental trauma are
major public health problems worldwide” (p.661). The relationship between oral health problems and
specific medical conditions is being substantiated by evidence from clinical, epidemiological and
laboratory studies. “Oral organisms have been linked to infections of the endocardium, meninges,
mediastinum, vertebrae, hepatobilary system and prosthetic joints” (Shay, 2002, p. 1215). In addition, oral
pain can have an economic impact on society through time away from work, lost productivity and
increased health care expenditures (Watt, 2005).

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Oral Health: Nursing Assessment and Interventions

Medical/Dental Interface
The emerging association between periodontal disease and systemic disease is a new area of research with
important implications for overall client health. The literature reports a link between oral health and
systemic disease. Salomon & Xiaozhe (2003) states that conditions such as cardiovascular disease, diabetes,
respiratory diseases and adverse pregnancy outcomes can be linked to oral health status. In a systematic
review, Chalmers (2003) reports, “dentate status, tooth loss and tempromandibular disorders are associated
with hearing loss. An increased number of missing teeth have been associated with coronary heart disease.
Periodontal diseases have been associated with cardiovascular diseases, atherosclerosis, sub-clinical lower
artery disease, stroke/cerebrovascular disease, metabolic/lipid disorders and obesity” (p.4). Periodontal
disease is emerging as a significant risk factor in the metabolic syndrome (heart disease, diabetes, and
stroke) (Chalmers, 2003).

Periodontal diseases (periodontitis and gingivitis) are multifactoral diseases with bacterial infiltration as an
essential component. Bacterial infection of the supporting structures of the teeth elicits an inflammatory
response. This chronic infection and inflammation of the gums establishes a systemic burden via the blood
stream of bacterial pathogens, bacterial antigens, endotoxins and inflammatory cytokines. Elevated
inflammatory cytokines, in particular C-reactive protein (CRP), destabilizes atherosclerotic plaques and
contributes to a prothrombic state. Dr Steven Offenbacker, member of the American Academy of
Periodontology states that “periodontal disease needs to be considered as a major contributor to increased
levels of CRP by the medical community” adding “previous studies reported that inflammatory effects from
periodontal disease could cause bacterial byproducts to enter the bloodstream and trigger the liver to make
proteins such as CRP that inflame arteries. The effects may cause blood clots that contribute to clogged
arteries leading to heart attacks and strokes” (American Academy of Periodontology, 2004).

In a recent treatment intervention study, Taylor et al. (2006) demonstrated that with full mouth tooth
extraction which eliminated periodontitis, lower systemic inflammatory and thrombotic markers of
cardiovascular risk were achieved. Shay (2002) describes “the total area of inflamed epithelial lining of
periodontal pockets in individuals with full dentition may exceed a surface area of 25 cm2” (p.1221) (this
can be visualized as approximately half the size of a credit card). This open tissue is at considerable risk for
the complications of infection.

Figure 1: Healthy Oral Cavity and Severe Periodontal Disease

Healthy oral cavity                       Severe Periodontal disease

Photos reproduced with permission:
Dr. David Clark, BSc, DDS, MSc, FAAOP, FRCDC
Faculty of Dentistry, University of Toronto

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Nursing Best Practice Guideline

Over the past two decades the prevalence of diabetes has increased 30 to 40%, and there is a bidirectional
association between glycemic control and periodontal disease (Ghezzi & Ship, 2000). Grossi et al. (1997) report
that the effective treatment of periodontal infection and reduction of periodontal inflammation is
associated with reduction in levels of glycated (glycolated) hemoglobin. It is therefore recommended that
control of periodontal infections should be an important part of the overall management of those with
diabetes mellitus (Grossi et al., 1997). The association between oral health and diabetic control was further
documented through research conducted by Engebretson et al. (2004) who found that poor glycemic control
was associated with elevated levels of gingival crevicular fluid (GCF) interleukin-1 beta (1L-1 beta).
Increased blood sugar levels cause inflammation in the gum tissue that may lead to increased destruction,
independent of bacterial load. Current research indicates that poor oral health is a prominent factor in a
number of other illnesses.

  Potential Impact of Moderate to Severe Periodontitis on the Body

  ■   Adverse Pregnancy Outcomes: 4-7 times greater risk
  ■   Chronic Respiratory Disease: 2-5 times greater risk
  ■   Coronary Artery Disease: 2 times greater risk
  ■   Diabetes: 2-4 times greater risk
  ■   Stroke: 2 times greater risk

  (Proceedings of the Periodontal-Systemic Connection: A State-of-the-Science Symposium. 2001.
  Annals of Periodontology, 6(1), 1-224.)

Vulnerable Populations
The greatest burden of oral disease is to disadvantaged and poor population groups, both in developing,
and developed countries (Petersen et al., 2005). Loeppeky and Sigal (2007) have identified people with special
needs who are in most need of meticulous oral hygiene: “physical, developmental, mental, sensory,
behavioural, cognitive or emotional impairment or a condition that requires medical management, health
care interventions or use of specialized services or programs” (p.915).

Residents of Long-Term Care Homes and/or Persons with Dementia
Canada’s population is aging quickly and according to new population projections the elderly (60-years-of-
age and older) will outnumber those under eighteen in 10 years. According to Health Canada’s report
Canada’s Aging Population (2002), the proportion of elderly in the overall population has gone from one in
20 in 1921, to one in eight in 2001. As “baby boomers” age (born between 1946 and 1965), the elderly
population is expected to reach 6.7 million in 2021, and 9.2 million in 2041 (nearly one in four Canadians).
In fact, the growth of the elderly population will account for close to half of the growth of the overall
Canadian population in the next four decades.

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Oral Health: Nursing Assessment and Interventions

The generation prior to the baby boomers predominantly lost most of their teeth, and the use of dentures
was very common. Baby boomers and subsequent generations have had the benefit of access to
preventative and restorative dental care throughout their lives, and people are retaining their teeth longer.
This next cohort of elderly is better educated, are more aware of the importance of maintaining oral health,
and expects comprehensive services from health care providers. Ghezzi, (2000), explains “this concept of
compression of morbidity requires aggressive application of preventive health measures. If oral health can
be maintained across a person’s lifespan, this will contribute to improved quality of life and successful
aging” (p.295). However, this population will be entering into a time in their life that is often associated with
impaired self-care. The combination of impaired self-care and greater tooth retention will increase their
risk for dental and periodontal diseases.

“Aspiration of oropharyngeal (including periodontal) pathogens is the dominant cause of nursing home-
acquired pneumonia; factors reflecting poor oral health strongly correlate with increased risk of developing
aspiration pneumonia” (Shay, 2002, p.1215). Nursing home-acquired pneumonia is the leading cause of death
from infection in long-term care home residents, and is the second most common cause for hospitalization
(Oh, Weintraub & Dhanani, 2004; Shay, 2002). Not brushing the teeth or not receiving adequate oral hygiene care
significantly increases oral bacteria in the saliva that residents swallow and may aspirate. Reduced salivary
flow, a common side effect of many medications, increases the concentration of bacteria in the saliva, and if
the saliva is aspirated, or more likely mixed with food or fluids, up to 100 million bacteria per ml could enter
the lungs. A resident with dysphagia is more likely to aspirate in quantities that may far exceed 1 ml (Langmore
et al., 1998). “ Poor oral hygiene, plaque accretion and compromised host defense that accompany periodontal
breakdown also provide conditions favourable for proliferation and subsequent aspiration of orally
incubated pulmonary pathogens” (Shay, 2002, p.1219). Inflammation of the gums is caused by bacterial plaque.
In older people, inflammation forms faster in response to plaque and responds more slowly when plaque is
removed (Shay, 2002), hence the importance of regular plaque control through oral hygiene measures.

Along with the increasing elderly population, the number of persons suffering from dementia continues to
rise in Canada. Alzheimer’s Disease is the most common form of dementia, and accounts for 64% of all
dementias. Alzheimer’s is a progressive, degenerative disease of the brain that causes thinking and memory
to become seriously impaired. Dementia is a syndrome consisting of a number of symptoms that include
loss of memory, judgment and reasoning, and changes in mood, behaviour and communication abilities.
In 2007 an estimated 97,000 Canadians developed Alzheimer’s or a related disease; an estimated 450,000
Canadians over 65-years-of-age have Alzheimer’s or a related disease. By 2011, new cases of dementia are
expected to reach 111,430 per year. Almost half of those with dementia live in the community, while half
live in long-term care homes (Alzheimer’s Society, 2007).

Dementia is a significant impairment and poses a particular challenge for caregivers due to behavioural
changes and decreased levels of cooperation. In her research with the dementia population, Chalmers
(2003), found that “participants with dementia had significantly higher experiences of oral diseases and
conditions at baseline and at one year compared with patients without dementia” (p.16). Additionally, her
findings indicated that plaque scores after one year were significantly higher for clients in care settings.

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Nursing Best Practice Guideline

Persons with Mental Illness
Persons with psychiatric illnesses, including those with schizophrenia, schizoaffective disorder, depression
and bipolar disorder may have their oral health compromised, not only by the illness, but also from the
medications used to treat the illness. These medications can cause a range of oral complications and side
effects, with tooth decay, periodontal diseases and xerostomia being encountered most frequently
(Almomani et al. 2006). Side effects of psychotropic medications may include tardive dyskinesia, which
impedes mobility of the limbs, and therefore, the ability to effectively brush the teeth.

Several factors contribute to the poor oral health of the person with mental illness:
■ The negative symptoms of schizophrenia, which may include apathy and avolition, decrease a person’s
  interest in attending to oral hygiene (Almomani et al. 2006; Jolly, 1991).
■ Cognitive deficits associated with schizophrenia and schizoaffective disorder can interfere with

  attention, memory, concentration and problem-solving skills.
■ Some medications used in the treatment of both schizophrenia and depression have an

  anticholinergic effect resulting in xerostomia. This hypo-salivation can result in rapid tooth decay and
  periodontal disease.
■ Many people with psychiatric illness have limited finances which adversely impacts on their

  nutritional status and the ability to access treatment in the community (Almomani et al. 2006).
■ Those with bipolar disorder exhibit one of the highest rates of associated substance abuse among all

  the major psychiatric illness (Clark, 2003).

In addition to the physical effects of prescription medications, substance abuse including alcohol, cocaine,
heroin and marijuana also can lead to gingivitis or tooth loss (Bailes, 1998). Further, “Meth Mouth” a condition
from the use of crystal methamphetamines results in a very rapid decay rate. Klassen (2006) confirms that the
level of decay that would normally take years to occur instead happens over a period of months.

Major depression is characterized by mood disturbances that can affect a person’s interest or pleasure in
daily activities of life. Depression is often accompanied by self-care deficits including oral hygiene
practices. In bipolar illness, mood fluctuates between periods of depression and elation, both exhibiting
lack of proper attention to oral hygiene

Almomani et al. (2006) cites a study by Barnes et al. (1988), which reported that a prime need for people with
psychiatric disorders included “prophylaxis, calculus removal and periodontal therapy” (p.274). It is further
reported (Hede, 1995 cited in Almomani et al., 2006) that only 55% of people with psychiatric disorders engaged
in regular tooth brushing. A study by Velasco and Bullon (1999) found the need for oral hygiene instruction
among the hospitalized dentate psychiatric population was determined to be 91.5% and for prophylactic
dental care was 77.3%. This client population often suffers from poor self-esteem and is stigmatized within
the community; poor oral hygiene stigmatizes this population further.

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Oral Health: Nursing Assessment and Interventions

Challenged Individuals
A) Physically and Mentally Challenged Individuals
The Surgeon’s General’s report on oral health indicates that individuals with mental retardation or with
other developmental disabilities, including Down’s Syndrome and Cerebral Palsy, have significantly higher
rates of poor oral hygiene and an increased need for periodontal treatment than the general population
(Glassman & Miller, 2003). It has been proposed that an exaggerated immune-inflammatory response occurs in
people with Down’s Syndrome (Chicon, Crawford & Grimm, 1998).

B) Stroke Survivor
Hospitalized survivors of acute stroke experience numerous sources of stress that can adversely affect oral
health (Heart and Stroke Foundation, 2006). These stressors include medications that cause dry mouth,
decreased alertness, cognitive and perceptual changes, neglect, depression, paralysis resulting in
immobility, dysphagia, apraxia, visual changes, mouth breathing and dehydration (Heart and Stroke
Foundation, 2006). Dysphagia is strongly associated with aspiration pneumonia, a pulmonary infection
caused by the entry of foreign substances and/or bacteria into the lungs. Some stroke survivors do not
regain consciousness, which may complicate the provision of care.

C) Individuals with Limited Dexterity
The ability to provide ones’ own oral care may be impacted by variety of causes including, but not limited
to, arthritic conditions, neurological diseases and amputations. Special consideration of these individuals
will be required in the provision of oral care, and can be determined during the assessment of the
individual. Planning for care should include an interdisciplinary approach.

Intensive (Critical) Care
The patient in the intensive care unit (ICU) poses unique challenges for the nurse. An increased cause of
morbidity and mortality among patients in the ICU is nosocomial infections and ventilator-acquired
pneumonia (VAP). In Canada, nosocomial pneumonia may be the second most common type of infection
acquired in hospital (Lux, 2007). Gingival and dental antiseptic decontamination significantly decreases the
oropharyngeal colonization by aerobic pathogens in ventilated patients (Founrier et al, 2005). Findings that
colonization of dental plaque could play a significant role in the occurrence of respiratory nosocomial
infections in ICU ventilated patients have been supported by other studies (Fourrier et al, 2005).

Often, the patient is admitted to care with good oral health, and it becomes the responsibility of the ICU
nurse to maintain that oral status while addressing the challenge of providing care under extremely
difficult circumstances. Providing care to an unconscious patient, one who is on a ventilator or one who
cannot swallow requires special attention to prevent aspiration pneumonia. Preventing oral disease in
those who may require a long convalescence or who may become permanently compromised is a
challenge for nursing care.

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Nursing Best Practice Guideline

Table 1: Oral signs and symptoms associated with patient stressors in the intensive care setting
  Stressor              Signs                                                Symptoms
  Mechanical ventilation and oxygen therapy
  Dry Mouth             ■   Dry, red mucosa and depapilated, lobulated       ■   Burning sensation
                            or fissured tongue                               ■   Dryness
                        ■   Dry, cracked lips                                ■   Difficulty swallowing
                        ■   Build up of debris in mouth
  Drug Therapy
  Immunosupression      ■   White plaques and inflammation                   ■   Pain or discomfort
  Change in Flora           associated with Candida albicans, herpetic       ■   Halitosis
                            ulcers, halitosis

  Xerostomia            ■   Decreased salivary flow                          ■   Burning sensation
                        ■   Dry, red mucosa and depapilated, lobulated       ■   Dryness
                            or fissured tongue                               ■   Difficulty swallowing
                        ■   Dry, cracked lips
                        ■   Build up of debris in mouth

  Therapeutic dehydration

  Xerostomia            ■   See above                                        ■   See above

Jones, 2005 (p.7)

Clients Receiving Chemotherapy or Radiotherapy
Mucositis is a painful complication of chemotherapy and/or radiotherapy, and good oral hygiene protocols
are important. Mucositis requires effective oral hygiene and a multi-disciplinary approach to management.
Infection of the gums prior to chemo or radiotherapy is a potential compounding factor and therefore,
when vulnerable populations are scheduled to have chemotherapy or radiotherapy, it is imperative that
prior to this treatment they have good oral health. Neutropenic patients with mucositis have an increased
risk for potentially life-threatening infections, as well as for prolonged hospital stays. Standard care of oral
mucositis is based on effective oral hygiene, appropriate analgesia, infection management and parenteral
nutrition when needed; few other approaches have been shown to be effective (Peterson & Cariello, 2004).

Barriers to Achieving Optimal Oral Health
The majority of caregivers, regardless of their category, have not been educated on how to care for the oral
hygiene of residents in long-term care (Chung, Mojon & Budtz-Jorgensen, 2000). Sumi et al. (2001) investigated
oral care practices among caregivers in Japanese nursing homes and found that 99% of staff desired the
development and dissemination of simple oral care equipment, while 97% wanted training in oral care.
Chalmers (2003) asserts that realistic, creative and practical strategies need to be developed and promoted
for caregivers in long-term care. It has also been reported in the literature that oral hygiene promotion
involves any combination of education, organizational, economic and environmental supports for
behaviour conducive to oral health (Croxson, 1993 as cited in Choo 1999).

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